Balkinization  

Tuesday, January 30, 2007

Tightening Control over the Federal Bureaucracy

JB

The New York Times features a story about the President's January 18th, 2007 Executive Order, which gives the White House greater control over the guidance documents that agencies produce. These guidance documents, while not themselves binding law, nevertheless strongly influence the way businesses comply with federal regulations. The new executive order imposes greater restrictions on when and for what purposes the agencies can write these documents; and it requires that they clear these advisory documents with regulatory policy offices staffed by political appointees of the Administration. The purpose is to ensure that the guidance documents are consistent with the Administration's policy views.

The new Executive Order amends a previous order promulgated in 1993 by the Clinton Administration, which also sought to bring the bureaucracy more under the control of the White House. In fact, the Clinton Adminstration introduced a number of changes designed to ensure that federal agencies better reflected the President's policy (and political) agenda. And Clinton's innovations, in turn, built on decisions made in the Reagan Administration.

It is true that the Bush Administration's new rule will give political appointees more say over the guidance documents that are produced by scientists and other experts in the civil service. It will increase the control that the White House and its political concerns have over the bureaucracy. But this development is best understood as the continuation of a trend that goes back through several administrations, both Republican and Democratic.

As the federal bureaucracy has grown larger and its orders and advice more frequent and pervasive, the bureaucracy has also become increasingly independent of the political will of the White House. Presidents, realizing this, have sought to bring the bureaucracy under their control in various ways. The Reagan Administration tried to slow down bureaucratic initiatives it did not like. The Clinton Administration tried to harmonize regulations and require additional justifications. The difference in strategies makes some sense: The Reagan Administration ran against government regulation, and so tried to control it by impeding it. The Clinton Administration, by contrast, tried to impose various good government reforms on regulation, and, perhaps more important, tried to take credit for the work that the bureaucracy was doing, particularly after the Democrats lost Congress following the 1994 elections. Thus, the President would often make public statements and hold press conferences to announce decisions made in the bureaucracy, declaring them to be initiatives (and successes) of his Administration. Where Reagan sought to rain on regulation's parade and slow it down, Clinton sought to run ahead of the parade so that he could lead it. (For those who are interested, Dean Elena Kagan of the Harvard Law School wrote an important study in the Harvard Law Review in 2001 comparing the Reagan and Clinton Administrations' attempts to control the federal bureaucracy, and this post draws on her analysis.)

Interestingly, the Bush Administration has built on the Clinton model more than the Reagan model. Instead of trying to halt regulation, it has sought greater political control over advisory documents and required a greater showing that regulation addresses a genuine market failure. It seeks to use political appointees to act as gatekeepers for the content of advisory documents before they are published.

The reasons why Bush has followed Clinton more than Reagan flow from the rise of Bush's big government conservatism, a conservatism that happily uses all the levers of federal power to benefit his political allies, including most particularly business interests, who remain central to the Republican political coalition. The Bush Administration does not so much seek to stop regulation as to mold it in a decidedly business-friendly way.

It no accident that these revisions occur following the Republican loss of Congress in 2006; both Congress and the President have varying degrees of influence over the bureaucracy; the Administration, faced with a Congress of the opposite party, is trying to ensure that its influence remains stronger. But it is likely that these changes would have occurred even if the Republicans retained Congress, because these changes are part of a longer trend of Presidents finding ever new ways of asserting control over the federal bureaucracy, and, more to the point, they mesh well with Bush's big government conservatism.

Critics may assume that the use of political appointees as gatekeepers is consistent with the Administration's "war on science." There may be something to that, but here is a better way to look at it. Scientific expertise is a source of authority for the bureaucracy; it justifies its independent judgment. Such independent judgment is precisely what Presidents seek to curb in asserting control over the bureaucracy. There is no one way to do this, of course. The Clinton Administration sought to require greater justification for bureaucratic policy initiatives with the idea of ultimately taking credit for the bureaucracy's best ideas. The Bush Administration has built on the Clinton model to some extent, but also tried a different approach, seeking to hew bureaucratic judgment more closely to the White House's political judgment. While both models assert political control over bureaucracy, the Bush strategy treats expertise more like a threat to Presidential authority than the Clinton model did. That should not be surprising. The "permanent campaign" of the Clinton Presidency has morphed and metastasized into the basic operations of governance in the Bush Administration. Critics often charge that the Bush Administration does not care much about policy debate, only about politics. The Bush Administration's distinctive solution to the conflict between the President and the bureaucracy reflects this larger tendency.


Comments:

Professor Balkin:

The Bush Administration has built on the Clinton model to some extent, but also tried a different approach, seeking to hew bureaucratic judgment more closely to the White House's political judgment.

I enjoyed your review of this story. What I found interesting was the way you and most other commentators on this executive order treated the executive and the bureaucracy as if they were different entities in our system of government, as if there was something strange about subsuming "bureaucratic judgment" to the President's "political judgement."

The last time I read the Constitution, the President was the sole executive and the executive departments were his or her subordinates. There is no provision of the Constitution which creates a fourth branch of the government made up of an independent unelected bureaucracy.

Therefore, the very fact that our elected Presidents need to issue executive orders in an often vain attempt to control the actions of the unelected bureaucracy should be more than a little disturbing to those who believe in the democratic republic created by the Constitution. Perhaps, Professor Levinson might like to add a section on this subject to his next book calling for wholesale revisions to the Constitution to make the government more democratic.
 

Unfortunately, the bureaucracy does act as a fourth branch of government, simply due to its size and inertia. Especially at the higher levels, when appointees move back and forth from consulting/lobbying to high level posts, depending on the political administration in control of the White House. I recall a business aphorism "the work will expand to fit the budget alloted to it" that particularly fits here.

However, I do question the use of the term "big government conservatism". From my recollection, conservatism is usually tied to small government proponents. What is being pushed here is better termed "business-friendly bureaucratism." A smaller bureaucracy would also be easier to control.
 

bart depalma writes: "Perhaps, Professor Levinson might like to add a section on this subject to his next book calling for wholesale revisions to the Constitution to make the government more democratic."

As a matter of fact, I think this is an important issue well worth discussing at the constitutional convention that I endorse. Whatever one's politics, it is clear that we have not worked out a truly compelling theory by which we balance off the benefits of "expert" bureaucratic decisionmaking with the legitimate demands of "politics" that includes, among other things, making hard choices about which values to prefer. The original proponents of the administrative state, such as Felix Frankfurter, had an exaggerated faith in "scientific administration"; one can well argue that the Bush Administratioin has too little respect for science, but that's neither here nor there. The importance of Jack's posting (and of my own addendum, I believe) is that even dedicated Bush-bashers can scarcely see this as a brand new development. The Kagan article that Jack cites is indeed extremely important. One doesn't have to buy into exaggerated theories of a "unitary executive" (which, among other things, would require a literally God-like omniescient president capable of making his/her own judgments about all sorts of issues about which
(s)he has no professional training, such as the probability of significant changes in the climate or the epidemeological consequences of adopting certain kinds of health policies, etc. Even if George W. Bush had Nobel Prizes in Economics and Physics, that would still not give him the professional knowledge to determine whether a particular mode of bridge building is actually safe or whether stem-cell research is likely to provide breakthroughs in the treatment of Parkinson's disease. That, I think, is the basic dilemma of contemporary politics, and democratic theorists (and constitutional designers) should indeed be working on it. The US Constitution, drafted in 1787, says absolutely nothing about the administrative state. A 21st century Constitution should, but I confess I don't have strong views on what exact it should say. That's exactly why I want to encourage a conversation about the weaknesses (and, to be sure, strengths) of our present constitutional order.
 

I don't think anyone would argue that this is a truly unprecedented move or an unconstitutional overstep of presidential authority; however, coming as it does from the Bush administration, it bespeaks of more of the same. As you say, bureaucratic expertise can represent a threat to is political agenda-- whether that be General Shinseki or the EPA. The Bush administration's response has consistently been not to respect the expertise of its own apolitical organs, but to silence them and attempt to subsume them into its political structure as much as possible. Policy becomes strictly the slave of politics.

That's not a good way to go about running a country.
 

Professor Levinson:

Thank you for your thoughtful reply. I never thought much of the argument in favor of an autonomous bureaucracy that only "experts" and "scientists" can make policy in complicated areas. Rather, these bureaucracy's role should be to advise the elected branches and then the elected representatives should make the policy.

For example, the bureaucracy should suggest rules to Congress and advise why it thinks the rules are necessary, then Congress should decide whether to enact the rules as suggested, amend them or reject them entirely just like any other legislation.

Likewise, the bureaucracy has no business acting as a quasi Article III court. Instead, Congress could enact a specialty Article III with the expertise in each area of law like environmental law which would be independent of the bureaucracy.

Finally, it is the President's job to enforce the law. To the extent that it enforces the law, the bureaucracy needs to be subservient to the President.
 

Its an interesting task - one man micromanaging each and every person working in all administrative offices everywhere.

Hiding political agendas behind the bravado of 'he must enforce the law' holds great promise for ignorant action. Suppose that somebody - left or right legislative or executive - presumes to legislate or dictate scientific truths, and prohibit building bridges using irrational constants or some such crazy thing. Not all truth is consensus. Some physical truths really don't care what people think of them.
 

Prof. Levinson... One doesn't have to buy into exaggerated theories of a "unitary executive" (which, among other things, would require a literally God-like omniescient president...

"Unitary Executive" intersects with
"Intelligent Design". Sweet.
 

Prof. Balkin [from the post]:

It is true that the Bush Administration's new rule will give political appointees more say over the guidance documents that are produced by scientists and other experts in the civil service. It will increase the control that the White House and its political concerns have over the bureaucracy.

This, coupled with the cronyism of the Dubya maladministration, is a recipe for disaster. Consider, e.g. the estimable Mr. Deutsch, the infamous Mr. "You're doing a heck of a job" Brown, and the hacks that contributed to the Iraq debacle.... It's not just "politicisation", it's crony welfare for incompetent (but loaded) Republican loyalists. Not even ideological, just craven power-grabbing for the Republican party cadres. Cadres? Yeah, this really is like the "political officers" in the old Soviet Union.

Cheers,
 

"Bart" DePalma says:

Therefore, the very fact that our elected Presidents need to issue executive orders in an often vain attempt to control the actions of the unelected bureaucracy should be more than a little disturbing to those who believe in the democratic republic created by the Constitution. Perhaps, Professor Levinson might like to add a section on this subject to his next book calling for wholesale revisions to the Constitution to make the government more democratic.

And if Dubya orders those scientists to get down on all fours and bark like a dog, they'd better do it ... or their a$$es are grass. The Friday Night Massacre comes to mind. There was an eventual response to that event; one that the Republicans have managed to kill off again. Perhaps time for another reappraisal....

Cheers,
 

Needless to say, I agree entirely with Broken Blogger that "this is no way to run a country." But this is an essentially (and altogether proper) political judgment about the judgment of the people running the country, and, to return to my broken-record theme, it is a terrible blot on our Constitution that it leaves us no way of getting rid of people who are "merely" misrunning the country. George W. Bush has 721 days remaining in office; he is not going to be impeached, nor will high-theory arguments about the proper allocation of power between civil servants and the President make any difference in what will happen over the next two years. Nor will Congress make a particular difference, as it musters its courage to pass "non-binding resolutions" and Mr. Banana-for-a-backbone, Arlen Specter, now says that decision-making power must be shared with Congress without committing himself to proposed legislation (that has no practical chance of passing, given filibusters and the presidential veto) that would indeed clip the president's expansive wings. That is the very meaning of being stuck in an "iron cage," alas.

Incidentally, just to try to foreclose another forty postings of more-or-less irrelevant debate, I will stipulate that there are people who don't share my view of the Bush presidency and who believe that the President's plan, which receives a heartfelt defense in today's Wall Street Journal, is indeed the best of an admittedly bad set of alternatives. The question for you is whether you would be complacent about keeping a president in office if you believed that his/her policies were indeed disastrous (but, by stipulation, not "criminal").
 

broken blogger:

The Bush administration's response has consistently been not to respect the expertise of its own apolitical organs, but to silence them and attempt to subsume them into its political structure as much as possible. Policy becomes strictly the slave of politics.

Perhaps part of the cure is not to deny the (mal)administration the ability to set policy, for better or for worse, but rather to strengthen the free-speech rights of those in the bureaucratic arms of the gummint. I don't think these two different objectives are irreconcilable. Just as no external criticism of administration policy doesn't unconstitutionally hamstring the gummint, criticism from inside doesn't prevent the gummint from doing what it decides to do, and there is definitely a case to be made for the Constitutional right to freedom of speech of gummint employees.

Cheers,
 

Mr depalma: The last time I read the Constitution, the President was the sole executive and the executive departments were his or her subordinates

This is a simplistic view of the way the government works. Congress has an interest in seeing that the laws it passes are executed well, according to the language of the laws. Most members of the executive also want to execute the laws in conformity with how they are written. In a presidential system, however, there is a built in divided loyalty for the members of the executive. The bureaucracy wants to do what the legislature directs it to do, but they are hired and fired by the president, not the legislature. Theoretically the president has no interest in what the laws are, only to see that they are faithfully executed. In reality, however, the president does have an interest, and these often conflict with what the legislature intended, even when the two are of the same party. This has been a perennial problem for our presidential system. In a parliamentary system there is no such conflict: the executive is clearly and only answerable to the legislature.

Efforts of the president to tighten his grip on the bureaucracy only serves to exacerbate the inherent problem of the bureaucracy's divided loyalty.

GYL
 

The Friday Night Massacre comes to mind.

I assume you mean the Saturday Night Massacre. I remember it well -- the day I took the LSAT.
 

"Bart" DePalma says:

I never thought much of the argument in favor of an autonomous bureaucracy that only "experts" and "scientists" can make policy in complicated areas.

"Straw man".

Of course, what we have is a balance between political and bureaucratic (and hopefully less political) interests. Most rational people would say that there ought to be some sort of a balance; "Bart" seems to think that the Constitution mandates no balance at all. Perhaps, but some people have argued that "the Constitution is not a suicide pact" either.

In point of fact, there are grounds for outside control on the government bureaucracy, and it is not exclusively the prvince of the executive. Regulations must (as the Constitution demands) simply carry out or effectuate legislative acts. The administration is not free to propagate any rules it wants; rule-making is subject to both Congressional oversight and the requirements of the APA (or whatever other legislation is passed to enable a regulatory process). If Congress were to adopt new procedures for rule-making that specifies specifically that Dubya's executive order regarding such "political appointees" is improper and invalid, that would be the new law, and Dubya would have to follow. For that matter, if Congress were to remove all regulatory authority from the executive, that would be its prerogative as well.

Cheers,
 

Mark Field:

[Arne]: The Friday Night Massacre comes to mind.

I assume you mean the Saturday Night Massacre. I remember it well -- the day I took the LSAT.


You're quite right. Brain spasm ... or senescence seems to have seeped in. Mea culpa and thanks.

Cheers,
 

Gary Larsen,

That is true, but is one reason why there were various civil service laws passed, to prevent the bureaucracy from being completely beholden to the president. I don't think it has much effect at the top (which are direct appointees--although confirmed by the Senate), although there are many cases of non-cabinet level posts not changed out immediately or thoroughly (Tenet comes to recent mind).

The bureaucracy is large (bloated?), however, and perhaps the best solution (conservative, liberal, libertarian, or any stripe) is to reduce it, to make it more responsive to both the executive and legislative branches, and hopefully the citizenry. This does not require a constitutional revision, mainly political will and consensus.
 

gary:

The bureaucracy wants to do what the legislature directs it to do...

When the direction is as broad as most of the enabling statutes passed by Congress, then Congress has delegated most of its policy making authority to the bureaucracy.

...but they are hired and fired by the president, not the legislature

Under the civil service rules, the President neither hires nor fires the vast majority of those who work in the bureaucracy.

In a parliamentary system there is no such conflict: the executive is clearly and only answerable to the legislature.

Actually, the most fundamental problem with the bureaucracy would not be eliminated in a parliamentary system. That problem is the legislature's delegation of its legislative authority to the bureaucracy.
 

Bart,

I agree on the legislative abandonment of their duties. When they continually write laws which basically tell the bureaucracy to write the rules, they avoid their own duty to do the same.

I see this all the time on financial legislation, and am then amused (not) when you see congresspeople sending in comments to the Fed (irony writ large) on how they would like them to interpret the rules that Congress asked them to create.
 

bart:

If you believe that the fundamental problem of the bureaucracy is the delegation of legislative authority, then I agree that a parliamentary system does not solve that. But such delegation is inevitable in any complex government: it began with the first session of Congress. To me the fundamental problem is rather the confusion and inefficiency that results when there is divided loyalty, uncertain responsibility. Such confusion is only an invitation to corruption. At least in a parliamentary system the lines of ultimate responsibility are clear.

GYL
 

Fraud Guy:

I agree on the legislative abandonment of their duties. When they continually write laws which basically tell the bureaucracy to write the rules, they avoid their own duty to do the same.

Legislating is a plenary, nondelegable power of Congress. Congress cannot "abandon" their duties to write laws, nor may they assign law-making power to anyone else. Courts have held that: 1). Congress must pass laws specifically enabling regulations to implement them, and 2). the regulations that are implemented must fall within the ambit of the enabling legislation, must carry out the laws as passed by Congress, and cannot exceed the bounds of those laws to achieve other purposes. Of course, words (and intentions) being slippery, regulations have in many cases expanded to fit all space available, and sometimes arguably slipped over the line, with the courts being less than rigourous in enforcing the line against transgressions ... but in theory the boundary is still there, and is a Constitutional one. But courts have never held (TTBOMK) that Congress may not pass general legislation and leave to the executive the instittion of regulations needed to implement the specifics of such. As such, the executive is not free, legally or even Constitutionally to run the regulatory apparatus any way it likes (and more than it is free to decide which laws it wants to enforce).

Same goes for declarations of war, FWIW. While the recent sentiment is that both the details of specific regulation and the exigencies of combat in a time of undeclared and ill-defined (and proxy) wars, not to mention supersonic missiles and nuclear weapons, militate for according more authority to the executive in today's modern world, if in fact this be the case, it should be done by changing the Constitution, not ignoring it or honouring it mostly in the breach.

Cheers,
 

The underlying problem here is that the executive (and I consider the bureaucracy to be part of the executive) has gotten much bigger and more powerful much faster than the legislature. This trend is not limited to the US federal government; it exists at all levels of government and world-wide.

The legislative power of the federal government has grown a great deal since 1787. But the legislative power of government in general has not. Extremely intrusive and meddlesome legislation is very old indeed. (Try reading the Pentateuch for the law code of the ancient Hebrews). But the power of government in general to execute its laws has grown immensely since the Constitution was written.

I do not think we can prevent or reverse this immense growth in executive power; it is the result of modern society's commercialization, specialization and expansion in technical fields of knowledge. The question is what to do about it.

Parliamentary governments dispense with an independent executive altogether. Many states of the US divide the executive by having different executive heads elected separately. The US federal government is in a difficult bind. Subordinate all executive agencies to the President, and his power is alarming. Encourage the independence of different agencies, and the bureaucracy becomes unaccountable.

I agree both with the people who say Congress is abdicating its responsibilities and with the ones who say that some such delegation is necessary and inevitable. What we need is some clear line making clear that Congress is not allowed to delegate policy decisions, but only the technical details. A very difficult line to draw, I realize.
 

While it is true that the 4th branch bureacracy may be unelected, the fact of the matter is that the US is a Republic, and significant power is delegated to unelected persons (ahem, SCOTUS?). Agency heads are charged with administering legislation drafted by Congress and advising the president and the Congress (e.g. via sworn testimony) concerning matters which fall under the agency's purview. They are not an extension of the president's communications staff. When we have an EPA administrator denying global warming because the energy lobby which funds the president and his party find the idea inconvenient, the system is clearly malfunctioning.

The best solution would be to limit the choices the president has in determining agency heads.

I propose that the merit-based system of civil service exams be extended to include political appointees. First, the president should be required to pick from the agency in question and such person shall be required to have served in that agency for a minimum number of years in order to be elegible for elevation to agency head. Second, a standardized Civil Service-type exam shall be administered which covers the required knowledge base for each agency. A cut-off would be administered to further limit the president's choice for the nominee--the percentile cut-off would be engineered on a sliding scale so as to give the president a choice from a minimum of say, ten or twenty applicants. Finally, a degree in a relevant field from a US-accredited school ought to be a requirement for elevation to the top of an agency. For example, the EPA administrator ought to be required to have at least an undergraduate degree in a hard/natural science.

While this may sound unegalitarian, it is not unprecedented. I don't need to point out to anyone on this blog that you must be a member of the bar to practice law in a given state, or that you must be qualified in the natural sciences to be a patent agent. Such requirements maintain the public confidence in the system that their tax dollars fund, and provide an atmosphere under which civil servants would strive to be the best and most knowledgable in their area of employment. Experience has demonstrated time and again that career bureaucrats are far better at their job than the well-connected Michael Brown's of the world; the spoils-based system only favors unaccountability and inefficiency.
 

Keith: I agree that the best solution would be to limit the choices the president has in determining agency heads, but I would rather have Congress itself limit those choices than the Civil Service, which is not really designed to make political appointments. This would go a long way to reducing the conflict between Congress and the executive.

GYL
 

mesothelioma Mesotheliomais a form of cancer that is almost always caused by exposure to Asbestos In this disease, malignant cells develop in the mesothelium, a protective lining that covers most of the body's internal organs. Its most common site is the pleura (outer lining of the lungs and internal chest wall), but it may also occur in the peritoneum (the lining of the abdominal cavity), the heart the pericardium (a sac that surrounds the heart or tunica vaginalis.
Most people who develop
mesothelioma have worked on jobs where they inhaled asbestos particles, or they have been exposed to asbestos dust and fiber in other ways. Washing the clothes of a family member who worked with asbestos can also put a person at risk for developing Mesothelioma Unlike lung cancer, there is no association between mesothelioma and smoking but smoking greatly increases risk of other asbestos induced cancer.Compensation via
Asbestos funds or lawsuits is an important issue in
mesothelioma The symptoms of
mesothelioma include shortness of breath due to pleural effusion (fluid between the lung and the chest wall or chest wall pain, and general symptoms such as weight loss. The diagnosis may be suspected with chest X-ray and CT scan and is confirmed with a biopsy (tissue sample) and microscopic examination. A thoracoscopy inserting a tube with a camera into the chest) can be used to take biopsies. It allows the introduction of substances such as talc to obliterate the pleural space (called pleurodesis, which prevents more fluid from accumulating and pressing on the lung. Despite treatment with chemotherapy, radiation therapy or sometimes surgery, the disease carries a poor prognosis. Research about screening tests for the early detection of mesothelioma is ongoing.
Symptoms of mesothelioma may not appear until 20 to 50 years after exposure to asbestos. Shortness of breath, cough, and pain in the chest due to an accumulation of fluid in the pleural space are often symptoms of pleural
mesotheliomaSymptoms of peritoneal
mesothelioma include weight loss and cachexia, abdominal swelling and pain due to ascites (a buildup of fluid in the abdominal cavity). Other symptoms of peritoneal
mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by
mesothelioma or by other, less serious conditions.
Mesothelioma that affects the pleura can cause these signs and symptoms:
chest wall pain
pleural effusion, or fluid surrounding the lung
shortness of breath
fatigue or anemia
wheezing, hoarseness, or cough
blood in the sputum (fluid) coughed up hemoptysis
In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung The disease may metastasize, or spread, to other parts of the body.
Tumors that affect the abdominal cavity often do not cause symptoms until they are at a late stage. Symptoms include:
abdominal pain
ascites, or an abnormal buildup of fluid in the abdomen
a mass in the abdomen
problems with bowel function
weight loss
In severe cases of the disease, the following signs and symptoms may be present:
blood clots in the veins, which may cause thrombophlebitis
disseminated intravascular coagulation a disorder causing severe bleeding in many body organs
jaundice, or yellowing of the eyes and skin
low blood sugar level
pleural effusion
pulmonary emboli, or blood clots in the arteries of the lungs
severe ascites
A
mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs
Diagnosing
mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history. A history of exposure to asbestos may increase clinical suspicion for
mesothelioma A physical examination is performed, followed by chest X-ray and often lung function tests. The X-ray may reveal pleural thickening commonly seen after asbestos exposure and increases suspicion of
mesothelioma A CT (or CAT) scan or an MRI is usually performed. If a large amount of fluid is present, abnormal cells may be detected by cytology if this fluid is aspirated with a syringe. For pleural fluid this is done by a pleural tap or chest drain, in ascites with an paracentesis or ascitic drain and in a pericardial effusion with pericardiocentesis. While absence of malignant cells on cytology does not completely exclude
mesothelioma it makes it much more unlikely, especially if an alternative diagnosis can be made (e.g. tuberculosis, heart failure
If cytology is positive or a plaque is regarded as suspicious, a biopsy is needed to confirm a diagnosis of
mesothelioma A doctor removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples.
If the cancer is in the abdomen, the doctor may perform a laparoscopy. To obtain tissue for examination, the doctor makes a small incision in the abdomen and inserts a special instrument into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
There is no universally agreed protocol for screening people who have been exposed to
asbestosScreening tests might diagnose mesothelioma earlier than conventional methods thus improving the survival prospects for patients. The serum osteopontin level might be useful in screening asbestos-exposed people for
mesotheliomaThe level of soluble mesothelin-related protein is elevated in the serum of about 75% of patients at diagnosis and it has been suggested that it may be useful for screening. Doctors have begun testing the Mesomark assay which measures levels of soluble mesothelin-related proteins (SMRPs) released by diseased mesothelioma cells
Incidence
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. The incidence rate is approximately one per 1,000,000. The highest incidence is found in Britain, Australia and Belgium: 30 per 1,000,000 per year. For comparison, populations with high levels of smoking can have a lung cancer incidence of over 1,000 per 1,000,000. Incidence of malignant mesothelioma currently ranges from about 7 to 40 per 1,000,000 in industrialized Western nations, depending on the amount of asbestos exposure of the populations during the past several decades. It has been estimated that incidence may have peaked at 15 per 1,000,000 in the United States in 2004. Incidence is expected to continue increasing in other parts of the world. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age. Approximately one fifth to one third of all mesotheliomas are peritoneal.
Between 1940 and 1979, approximately 27.5 million people were occupationally exposed to asbestos in the United States.[ Between 1973 and 1984, there has been a threefold increase in the diagnosis of pleural mesothelioma in Caucasian males. From 1980 to the late 1990s, the death rate from mesothelioma in the USA increased from 2,000 per year to 3,000, with men four times more likely to acquire it than women. These rates may not be accurate, since it is possible that many cases of mesothelioma are misdiagnosed as adenocarcinoma of the lung, which is difficult to differentiate from mesothelioma.
Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure exists in almost all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos. In rare cases, mesothelioma has also been associated with irradiation, intrapleural thorium dioxide (Thorotrast), and inhalation of other fibrous silicates, such as erionite.
asbestos
is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven.
asbestos
has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
The combination of smoking and
asbestos exposure significantly increases a person's risk of developing cancer of the airways (lung cancer bronchial carcinoma). The Kent brand of cigarettes used
mesothelioma in its filters for the first few years of production in the 1950s and some cases of
mesothelioma have resulted. Smoking modern cigarettes does not appear to increase the risk of mesothelioma.
Some studies suggest that simian virus 40 may act as a cofactor in the development of mesothelioma.
Asbestos was known in antiquity, but it wasn't mined and widely used commercially until the late 1800s. Its use greatly increased during World War II Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with
asbestos exposure were not publicly known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of
asbestos exposure in the workplace, and created guidelines for engineering controls and respirators, protective clothing, exposure monitoring, hygiene facilities and practices, warning signs, labeling, recordkeeping, and medical exams. By contrast, the British Government's Health and Safety Executive (HSE) states formally that any threshold for
mesothelioma must be at a very low level and it is widely agreed that if any such threshold does exist at all, then it cannot currently be quantified. For practical purposes, therefore, HSE does not assume that any such threshold exists. People who work with
asbestos wear personal protective equipment to lower their risk of exposure. Recent findings have shown that a mineral called erionite has been known to cause genetically pre-dispositioned individuals to have malignant mesothelioma rates much higher than those not pre-dispositioned genetically. A study in Cappadocia, Turkey has shown that 3 villiages in Turkey have death rates of 51% attributed to erionite related
mesotheliomaExposure to
asbestos fibres has been recognised as an occupational health hazard since the early 1900s. Several epidemiological studies have associated exposure to asbestos with the development of lesions such as asbestos bodies in the sputum, pleural plaques, diffuse pleural thickening, asbestosis, carcinoma of the lung and larynx, gastrointestinal tumours, and diffuse mesothelioma of the pleura and peritoneum.
The documented presence of
asbestos fibres in water supplies and food products has fostered concerns about the possible impact of long-term and, as yet, unknown exposure of the general population to these fibres. Although many authorities consider brief or transient exposure to
asbestos fibres as inconsequential and an unlikely risk factor, some epidemiologists claim that there is no risk threshold. Cases of mesothelioma have been found in people whose only exposure was breathing the air through ventilation systems. Other cases had very minimal (3 months or less) direct exposure.
Commercial
asbestos mining at Wittenoom, Western Australia, occurred between 1945 and 1966. A cohort study of miners employed at the mine reported that while no deaths occurred within the first 10 years after crocidolite exposure, 85 deaths attributable to mesothelioma had occurred by 1985. By 1994, 539 reported deaths due to mesothelioma had been reported in Western Australia.
Family members and others living with
asbestos workers have an increased risk of developing
mesothelioma and possibly other asbestos related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to asbestosMany building materials used in both public and domestic premises prior to the banning of
asbestos may contain
asbestos Those performing renovation works or activities may expose themselves to asbestos dust. In the UK use of Chrysotile asbestos was banned at the end of 1999. Brown and blue
asbestos was banned in the UK around 1985. Buildings built or renovated prior to these dates may contain asbestos materials.
For patients with localized disease, and who can tolerate a radical surgery, radiation is often given post-operatively as a consolidative treatment. The entire hemi-thorax is treated with radiation therapy, often given simultaneously with chemotherapy. Delivering radiation and chemotherapy after a radical surgery has led to extended life expectancy in selected patient populations with some patients surviving more than 5 years. As part of a curative approach to
mesothelioma radiotherapy is also commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumor along the track in the chest wall.
Although
mesothelioma is generally resistant to curative treatment with radiotherapy alone, palliative treatment regimens are sometimes used to relieve symptoms arising from tumor growth, such as obstruction of a major blood vessel.
Radiation Therapy when given alone with curative intent has never been shown to improve survival from
mesothelioma The necessary radiation dose to treat mesothelioma that has not been surgically removed would be very toxic.
Chemotherapy is the only treatment for
mesothelioma that has been proven to improve survival in randomised and controlled trials. The landmark study published in 2003 by Vogelzang and colleagues compared cisplatin chemotherapy alone with a combination of cisplatin and pemetrexed (brand name Alimta) chemotherapy) in patients who had not received chemotherapy for malignant pleural mesothelioma previously and were not candidates for more aggressive "curative" surgery. This trial was the first to report a survival advantage from chemotherapy in malignant pleural
mesothelioma showing a statistically significant improvement in median survival from 10 months in the patients treated with cisplatin alone to 13.3 months in the combination pemetrexed group in patients who received supplementation with folate and vitamin B12. Vitamin supplementation was given to most patients in the trial and pemetrexed related side effects were significantly less in patients receiving pemetrexed when they also received daily oral folate 500mcg and intramuscular vitamin B12 1000mcg every 9 weeks compared with patients receiving pemetrexed without vitamin supplementation. The objective response rate increased from 20% in the cisplatin group to 46% in the combination pemetrexed group. Some side effects such as nausea and vomiting, stomatitis, and diarrhoea were more common in the combination pemetrexed group but only affected a minority of patients and overall the combination of pemetrexed and cisplatin was well tolerated when patients received vitamin supplementation; both quality of life and lung function tests improved in the combination pemetrexed group. In February 2004, the United States Food and Drug Administration approved pemetrexed for treatment of malignant pleural mesothelioma. However, there are still unanswered questions about the optimal use of chemotherapy, including when to start treatment, and the optimal number of cycles to give.
Cisplatin in combination with raltitrexed has shown an improvement in survival similar to that reported for pemetrexed in combination with cisplatin, but raltitrexed is no longer commercially available for this indication. For patients unable to tolerate pemetrexed, cisplatin in combination with gemcitabine or vinorelbine is an alternative, although a survival benefit has not been shown for these drugs. For patients in whom cisplatin cannot be used, carboplatin can be substituted but non-randomised data have shown lower response rates and high rates of haematological toxicity for carboplatin-based combinations, albeit with similar survival figures to patients receiving cisplatin.
In January 2009, the United States FDA approved using conventional therapies such as surgery in combination with radiation and or chemotherapy on stage I or II Mesothelioma after research conducted by a nationwide study by Duke University concluded an almost 50 point increase in remission rates.
Treatment regimens involving immunotherapy have yielded variable results. For example, intrapleural inoculation of Bacillus Calmette-Guérin (BCG) in an attempt to boost the immune response, was found to be of no benefit to the patient (while it may benefit patients with bladder cancer.
mesothelioma cells proved susceptible to in vitro lysis by LAK cells following activation by interleukin-2 (IL-2), but patients undergoing this particular therapy experienced major side effects. Indeed, this trial was suspended in view of the unacceptably high levels of IL-2 toxicity and the severity of side effects such as fever and cachexia. Nonetheless, other trials involving interferon alpha have proved more encouraging with 20% of patients experiencing a greater than 50% reduction in tumor mass combined with minimal side effects.
A procedure known as heated intraoperative intraperitoneal chemotherapy was developed by at the Washington Cancer Institute. The surgeon removes as much of the tumor as possible followed by the direct administration of a chemotherapy agent, heated to between 40 and 48°C, in the abdomen. The fluid is perfused for 60 to 120 minutes and then drained.
This technique permits the administration of high concentrations of selected drugs into the abdominal and pelvic surfaces. Heating the chemotherapy treatment increases the penetration of the drugs into tissues. Also, heating itself damages the malignant cells more than the normal cells.

What is the mesothelium?
The mesothelium is a membrane that covers and protects most of the internal organs of the body. It is composed of two layers of cells: One layer immediately surrounds the organ; the other forms a sac around it. The mesothelium produces a lubricating fluid that is released between these layers, allowing moving organs (such as the beating heart and the expanding and contracting lungs to glide easily against adjacent structures.
The mesothelium has different names, depending on its location in the body. The peritoneum is the mesothelial tissue that covers most of the organs in the abdominal cavity. The pleura is the membrane that surrounds the lungs and lines the wall of the chest cavity. The pericardium covers and protects the heart. The
mesothelioma tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.
What is mesothelioma?
mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs.
cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum.
How common is mesothelioma?
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. About 2,000 new cases of mesothelioma are diagnosed in the United States each year. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age.
What are the risk factors for mesothelioma?
Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to
Asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. asbestos has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
Smoking does not appear to increase the risk of mesothelioma. However, the combination of smoking and asbestos exposure significantly increases a person's risk of developing cancer of the air passageways in the lung.
Who is at increased risk for developing mesothelioma?
asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure.
The risk o f asbestosrelated disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma On the other hand, not all workers who are heavily exposed develop asbestos-related diseases.
There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma, and possibly other asbestos-related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to
asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.
What are the symptoms of mesothelioma?
Symptoms of mesothelioma may not appear until 30 to 50 years after exposure to
asbestos Shortness of breath and pain in the chest due to an accumulation of fluid in the pleura are often symptoms of pleural mesothelioma. Symptoms of peritoneal mesothelioma include weight loss and abdominal pain and swelling due to a buildup of fluid in the abdomen. Other symptoms of peritoneal mesothelioma may include bowel obstruction blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by
mesothelioma or by other, less serious conditions. It is important to see a doctor about any of these symptoms. Only a doctor can make a diagnosis
How is
mesotheliomadiagnosed?
Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful. A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed.
A biopsy is needed to confirm a diagnosis of mesothelioma. In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the
cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the
cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
If the diagnosis is mesothelioma, the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment.
Mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.
How is
mesotheliomatreated?
Treatment for mesothelioma depends on the location of the
cancerthe stage of the disease, and the patient's age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy. Sometimes, these treatments are combined.
Surgery is a common treatment for
mesotheliomaThe doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural
mesotheliomaa lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.
Stereo Tactic Radiation Therapy also called radiotherapy, involves the use of high-energy rays to kill
cancercells and shrink tumors Radiation therapy affects the
cancercells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the
cancercells are found (internal radiation therapy).
Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat
mesotheliomaare given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).
To relieve symptoms and control pain, the doctor may use a needle or a thin tube to drain fluid that has built up in the chest or abdomen. The procedure for removing fluid from the chest is called thoracentesis. Removal of fluid from the abdomen is called paracentesis. Drugs may be given through a tube in the chest to prevent more fluid from accumulating. Radiation Therapy and surgery may also be helpful in relieving symptoms.
 

Post a Comment

Older Posts
Newer Posts
Home